Insurance can be very confusing! There are many terms such as deductible, co-pay, max out-of-pocket, in-network vs out-of-network... and there's not a lot of resources out there that break in down and give it to you straight.
You may be wondering why I'm even writing about this...
The reason is because I have had several potential patients seek Physical Therapy elsewhere because they were thrown off by the fact that my clinic is "Out-Of-Network" with their insurance without fully understanding what that means.
First of all, this does NOT mean that I don't take your insurance!
But before we get into the nitty gritty let me break things down a bit:
Deductible = the amount of money you pay out of your pocket until your insurance will cover part or all of the expenses
This can range from $500 - $10,000!
Until your deductible is met, you are paying ALL of the medical expenses regardless if you're going to an "In-Network" or "Out-Of-Network" clinic.
In-Network Provider = the provider (physical therapy, physician, dentist, etc.) has contracted with your insurance company to provide negotiated (discounted) rates
On average, once the deductible is met, the insurance company pays for 80-100% for the cost of service being provided.
Out-Of-Network Provider = the provider (physical therapy, physician, dentist, etc.) has NOT contracted with your insurance company to provide negotiated (discounted) rates
On average, once the deductible is met, the insurance company pays for 50-70% for the cost of service being provided.
So why would I ever go to an Out-Of-Network Provider?
Most of my patients have such high deductible that they will not come close to reaching it with my services. So regardless if they are going to an "In-Network" or "Out-Of-Network" Physical Therapy clinic, they will be billed the SAME (meaning all out-of-pocket until the deductible is met).
However, for those who HAVE already met their deductible, most "Out-Of-Network" insurance plans cover at least 50-70% of costs.
Due to the In-Network negotiated rates, most outpatient clinics see 2-4 patients per hour! They also see the average patient for 2-3 times a week for 8-12 weeks (I used to work in an In-Network clinic so I know this from firsthand experience).
At my clinic, I typically see patients 1-2 times a week with an average of 5-8 sessions TOTAL.
If you do the math, the total costs average out to be very close if not LESS going to see me Out-Of-Network.
You don't need a physician's referral to schedule an appointment with me! You can see me directly and avoid the tedious appointments that can be both time-consuming and expensive!
My passion is helping adults and athletes (of all ages) get back to what they LOVE doing without relying on pain medications, injections, or surgeries!
Now is the time to take control of YOUR health and break from this nasty cycle that health care professionals have put you in. Your pain will no longer be overlooked!
Click on the link below for a super quick list of questions to ask your insurance provider!
Insurance Benefits Worksheet
If you've found this article helpful please let me know! I would love to hear feedback from you! And if you have any questions please feel free to shoot 'em my way!
Dr. Katie Spruell, PT, DPT, CSCS
Dr. Katie Spruell, PT, DPT, CSCS
I am a licensed Physical Therapist and Certified Strength & Conditioning Specialist practicing in Nashville, TN. I started a small private practice - KS Fitness + Co, LLC - in April 2018.